2024 NSG 200 FINAL EXAM WITH
CORRECT ANSWERS
A student is performing a physical assessment on a patient. While assessing
the abdomen, the student percusses the spleen. What sound would be
normal for the student to hear? - CORRECT-ANSWERStympany
An emergency department nurse is caring for a 17 year old patient who has
severe pain in the umbilical area. Documentation shows that the patient
exhibits "Rovsing's sign." What might this patient's medical diagnosis be? -
CORRECT-ANSWERSappendicitis
if a patient outputs more than they take in, what might this result in? -
CORRECT-ANSWERSdehydration
if a patient takes in more than they output, what might this result in? -
CORRECT-ANSWERSfluid overload
What is the normal capillary refill time? - CORRECT-ANSWERSless than 3
seconds
how do you test for visual acuity? - CORRECT-ANSWERSsnellen chart (looking
into someone's eyes does NOT determine visual acuity)
data you as a nurse observe, such as vital signs, lesions, visible findings are
referred to as...? - CORRECT-ANSWERSobjective data
things or symptoms that a patient tells you as the nurse, can vary and is not
always reliable, referred to as...? - CORRECT-ANSWERSsubjective data
what is the average intake/output per day? - CORRECT-ANSWERS2,000 mL
Questions like...
-weight gain/loss recently?
-frequency or burning w/urination?
-daily intake/output?
-UTI history? - CORRECT-ANSWERSGI health history questions
when a nurse conducts a smell test, what CN is she testing? - CORRECT-
ANSWERSCN 1 (olfactory)
, when the nurse uses a snellen chart to check for visual actuity, what CN is
she checking? - CORRECT-ANSWERSCN 2 (optic)
when the nurse draws an "H" with the tip of her pen and asks the patient to
follow with their head without moving their neck, what CN is she checking? -
CORRECT-ANSWERSCN 3, 4, 6 (eye movement)
when the nurse palpates the sinuses to check if the patient feels her touch,
and notices a patient smile/use facial expressions, what two CN can she
confirm are in tact? - CORRECT-ANSWERSCN 5 and 7 (facial)
when the nurse conducts a whisper test, what CN is she testing? - CORRECT-
ANSWERSCN 8 (acoustic)
when the nurse asks the patient to swallow, what CN is she testing for? -
CORRECT-ANSWERSCN 9 (glossopharyngeal)
when the nurse stimulates the gag reflex, which CN is she confirming is in
tact? - CORRECT-ANSWERSCN 10 (vagus)
when the patient shrugs their shoulders, what CN can the nurse confirm is in
tact? - CORRECT-ANSWERSCN 11 (accessory)
when the patient sticks out their tongue, what CN does the nurse realize is in
tact? - CORRECT-ANSWERSCN 12 (hypoglossal)
A nurse states that a patient is "oriented x4." What are these four criteria? -
CORRECT-ANSWERSperson, place, time and situation
tapping quality, soft and clear, increase in intensity - CORRECT-
ANSWERSkorotkoff phase I
no sound, silence for 30 to 40 mmHg during deflation; is an abnormal finding
- period when korotkoff sounds disappear during auscultation - CORRECT-
ANSWERSauscultatory gap
knocking quality, crisp and high-pitched sounds - CORRECT-
ANSWERSkorotkoff phase III
abrupt muffling quality, sound mutes to low-pitched, cushioned murmur;
blowing quality - CORRECT-ANSWERSkorotkoff phase IV
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